Prenatal care

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Goal (NIH)
Pregnant women Fetus Family
Provide primary preventive health care Promote maternal health care Reduce risk of maternal mortality and morbidity Reduce risk to health before subsequent pregnancy and beyond child bearing year Promote parenting skills

Goal (NIH)
Pregnant women Fetus Family
Reduce: Preterm, IUGR, Congenital anomalies Enhance fetal health, Reduced hospitalization Promote health: growth and development Reduce risk of neurological, development and other morbidities Reduce: child abuse, neglect, injuries, chronic illness

Goal (NIH)
Pregnant women Fetus Family
Promote family development, positive parent-infant interact. Reduced the number of unintended pregnancy Identify and treat behavioral disorder: child neglect and family violence

Goal
Healthy mother and child Risk and complications detection Health education

Preconception care
Family planning Health status & immunization Risk assessment
Nutritional status Medical disease Medication: Teratogens Social risk: Chemical, Violence Healthy risk: Alcohol, Smoking Genetic risk: Thalassemia, Aneuploidy

Initial prenatal visit

Diagnosis of pregnancy Define mother and fetal health status Determine gestational age of fetus Patient education Initiate a plan for continuing obstetrical care

Initial prenatal visit

History taking Physical examination Laboratory investigation

Personal history
Age: Teenage, elderly gravida Education Career, Environment: Chemical, Radiation exposure Drug use, Smoking, Alcohol Ethnicity: Genetic risk Religion, Psychosocial factor

Past history
Medical disease Medications & treatment Surgical: Abdominal surgery Psychiatric problems

Family history
Medical disease: Diabetes Infectious disease: Tuberculosis, Sexually transmitted disease Genetic disease, Anomaly Domestic violence risk

Obstetric history
Gravida, Parity, Abortion: ex. G2P1A0, G3P1012 Route, Place, Birth weight, Procedure Complications Infertility, Contraception

Menstrual history
Mernache Interval, Duration, Amount, Regular? Last menstrual period (LMP): Naegele rule:
EDD = (LMP + 7 days) 3 months Expected date of delivery (confinement)

Past menstrual period (PMP)

Physical examination
Weight, Height, Body mass index (BMI) Vital sign: BP, Pulse, Temperature Anemia, Oral cavity, Thyroid Cardiovascular & Respiratory system Breast examination: Breast feeding

Physical examination
Abdominal examination: Scar Leopold maneuver
Fundal height: Size v.s.Date Number Lie: Longitudinal, Transverse Fetal life:FHS (Doptone 12 wk, Stethoscope 20 wk)

Pelvic examination: Uterine size, STD, Abnormal mass?

Leopold maneuver
I II

Leopold maneuver
III IV

Fundal height
12 week: 1/3 > Suprapubic 16 week: 2/3 > Suprapubic 20 week: Umbilicus 24 week: 1/4 > Umbilicus 28 week: 2/4 > Umbilicus 32 week: 3/4 > Umbilicus 36 week: Just below xiphoid 40 week: Lightening

Fundal height

Investigation
Blood test
Hematocrit (Hemoglobin) Blood group, Rh VDRL or Rapid plasma reagin HBsAg, + Rubella titer anti HIV (Voluntary screening) Thalassemia screening:
OFT or MCVwith DCIP or Hb E screening

Investigation
Urine analysis Special investigation
Ultrasonography 50 gram-glucose challenge test Group B streptococcal screening Triple screening Fetal chromosome study

Initial prenatal visit

Diagnosis of pregnancy Define mother and fetal health status Determine gestational age of fetus Patient education Initiate a plan for continuing obstetrical care

Education
Nutrition
Avoid uncooked or undercooked Increased need: Weight gain 10-12 kg Iron supplement: 60-70 mg/day Folic acid supplement: 400 g/day Vitamin A supplement: >700 g/day Teratogen High mercury: Shark, Swordfish, Marlin Caffeine: < 300 mg/day

Education
Nutrition (continue)
Tuna: not more than 2 medium can or one fresh steak per week Milk: Pasteurised or UHT milk

Patient right, Hygiene, Dressing Travel: Air travel (Deep vein thrombosis, Vaccinations), Safety belt Maternal adaptation

Maternal adaption 1
Nausea and vomiting in early pregnancy: Ginger (250 mg qid), P6 acupressure, Antihistamines, Pyridoxine Heartburn: Antacid, H2 blocker Constipation: High fiber diet Hemorrhoids: High fiber diet Varicose veins: Stocking Bleeding gum or Gingivitis: Epulis

Maternal adaption 2
Vaginal discharge: Increased vaginal discharge Backage: Exercise in the water, Massage therapy, Group or individual back care class Symphysis pubis dysfunction Carpal tunnel syndrome Swelling or Edema: Lower extremities Frequency of urination

Education
Contraceptive: postpartum Labor and delivery option Smoking cessation Medication during pregnancy:
Over-the counter medicine

Immunization: TT, Other Sign and symptom of labor pain

Education
Alcohol and drug abuse STDs and HIV risk reduction Physical, Sexual activity, Exercise Domestic violence Abnormal sign and symptom Subsequent visit

Subsequent prenatal assessment

Frequency
< 28 week : q 4 week 28-36 week : q 2 week > 36 week : q 1 week

Subsequent prenatal assessment

History taking
Abnormal sign and symptom Quickening (G1:18-20 week, G2 16-18 week) Fetal movement count (After 28 week)

Physical examination

Subsequent prenatal assessment

Physical examination
Blood pressure Weight Uterine size Fetal heart rate Edema

Subsequent prenatal assessment

Investigation
Urine protein and sugar Special investigation
Ultrasonography 50 gram-glucose challenge test Group B streptococcal screening Triple screening

Goal
Healthy mother and child Risk and complication detection Health education